PART 4  •  The Shoulder Region in Upper Extremity Pain Syndromes
Chapter
Therapeutic Exercises for the Shoulder Region
CHAPTER CONTENTS
Introduction 373
Clinical background 373
Shoulder exercise: evidence 374
Principles of exercise 374
Posture 376
Stretching 376
Isometric exercise of the shoulder 378
Isotonic exercises of the shoulder 378
Supraspinatus muscle 379
Infraspinatus and teres minor muscles 379
Subscapularis muscle 380
Trapezius muscle 380
Serratus anterior muscle 381
Functional exercises 381
Conclusion 383
Introduction
Therapeutic exercise is a cornerstone of physiotherapy prac-
tice and was initially referred to as medical gymnastics. The
development of medical gymnastics in physical therapy has
had many diverse influences including Dr Francis Fuller,
author of Medicina gymnasticia (1740), Swedish gymnast Per
Henrik Ling (1776–1839) and the Dutch physical education
teacher and physician Dr Johann Georg Mezger (1838–1909)
(Barclay 1994; Terlouw 2007). More recently Kendall (2002)
summed up the role of therapeutic exercise in physical
therapy: ‘Central to the practice of physical therapy is the
prevention of movement dysfunction and the rehabilitation
through restoration and maintenance of active movement – in
other words, therapeutic exercise in its broadest sense’. The
focus of this chapter is to introduce general principles of
therapeutic exercise for the shoulder, and to stimulate
clinical reasoning and rational rehabilitation. The chapter will
briefly discuss posture, stretching and strengthening of a
33  
Johnson McEvoy, Kieran O’Sullivan, Carel Bron
selection of muscles, without focusing on one specific clinical
population.
Clinical Background
Essential to an understanding of therapeutic exercise is an
in-depth knowledge of anatomy, physiology and function,
specifically related to the neuromuscular and musculoskeletal
systems (Kendall 2002). The shoulder is a complex functional
system producing movement of the arm on the trunk and
allowing the upper limb and hand to be dynamically moved
and positioned for function. The shoulder consists of the
scapula, clavicle and humerus, giving rise to the sternocla-
vicular, clavicular, humeral and scapulothoracic joints, and
has a close relationship to the neck, thorax and ribs. The
shoulder is supported by capsular, ligamentous and muscular
systems with complex neuromuscular processing that offer a
wide range of motion, but with a subsequent compromise in
joint stability. This trade-off in stability makes the shoulder
potentially vulnerable to dysfunction and injury, and stability
is often the main focus of therapeutic exercise for the shoulder
complex. Readers should refer to the appropriate chapters
of this book and other texts for a comprehensive review of
shoulder anatomy, biomechanics, kinesiology and pathome-
chanics (Donatelli 2004a; Oatis 2004). Further, knowledge of
connective tissue properties, force applications, tissue injury
(bone, ligament, tendon, muscle, fascia, nerve, etc.) and tissue-
healing concepts and timelines (inflammation, proliferation,
maturation) is an important precursor to the development of
a suitable and safe therapeutic exercise programme (Tippet &
Voight 1995; Paris & Loubert 1999; Houglum 2005).
Prior to the development of a rehabilitation programme for
the shoulder complex a comprehensive assessment and physi-
cal examination should be performed with reference to the
principles of physical therapy practice so as to ascertain per-
tinent information and physical characteristics of the indi-
vidual patient. Indications for therapeutic exercise of the
shoulder are listed in Box 33.1 and are diverse; they include
specific and non-specific musculoskeletal, orthopaedic, surgi-
cal and neurological conditions and dysfunctions, and also
postural and performance enhancement and injury preven-
tion strategy.
 374 PART 4  • 33 • Therapeutic exercises for the shoulder region
Box 33.1  Indications for therapeutic shoulder
exercises
• Glenohumeral joint lesions, dysfunctions and instability
• Rotator cuff lesions and dysfunctions
• Subacromial impingement syndrome
• Acromioclavicular joint lesions and dysfunctions
• Sternoclavicular joint lesions and dysfunctions
• Superior labrum anterior-to-posterior (SLAP) lesions
• Adhesive capsulitis (frozen shoulder)
• Arthropathies: arthrosis, arthritis, rheumatoid arthritis
• Post fracture and trauma
• Soft tissue injuries and syndromes
• Sports injuries
• Myofascial pain and dysfunction from trigger points
• Hypermobility syndromes
• Postural dysfunction
• Movement disorders
• Performance enhancement and performance optimization
• Injury prevention
• Post shoulder surgery and arthroscopy
• Shoulder replacement
• Thoracic surgery with shoulder involvement (e.g.
mastectomy)
• Spinal cord injuries and nerve root syndromes
• Peripheral nerve injuries
• Central nervous system disorders (e.g. hemiplegia)
Shoulder Exercise: Evidence
A wide variety of shoulder disorders have demonstrated
alterations in shoulder range of motion (Hall & Elvey 1999;
Vermeulen et al 2002; McClure et al 2006), scapular kinemat-
ics (Lukasiewicz et al 1999; Ludewig & Cook 2000; McClure
et al 2006; Roy et al 2009; Tate et al 2009), scapular and rotator
cuff muscle activation (Ludewig & Cook 2000; Cools et al
2007; Moraes et al 2008; Myers et al 2009), humeral translation
(Chen et al 1999; Ludewig & Cook 2002), repositioning sense
(Naughton et al 2005) and shoulder strength (McClure et al
2006; Lombardi et al 2008; Baydar et al 2009; Bigoni et al
2009). Therefore, therapeutic exercises are commonly advo-
cated to address these dysfunctions in mobility, posture,
muscle activation, proprioception and strength.
Overall, the evidence that therapeutic exercise is effective
for non-specific shoulder pain is mixed (Smidt et al 2005),
similar to other approaches including manual therapy (Ho
et al 2009) and acupuncture (Green et al 2005). However,
exercise appears to be as effective for non-specific shoulder
pain as more expensive treatments such as multidisciplinary
bio-psychosocial rehabilitation (Karjalainen et al 2001). Fur-
thermore, when specific shoulder disorders are considered
there is little evidence that alternative approaches are supe-
rior to therapeutic exercise. For example medium- and long-
term outcomes after therapeutic exercise in adhesive capsulitis
are similar to those after other treatments including arthro-
graphic distension (Buchbinder et al 2008) and corticosteroid
injection (Winters et al 1997, 1999; Buchbinder et al 2003).
There is also evidence that combining corticosteroid injection
with physiotherapy including therapeutic exercise results in
greater improvement than either treatment in isolation
(Carette et al 2003).
The use of therapeutic exercise in the management of
specific disorders including subacromial impingement syn-
drome (SAIS) and rotator cuff lesions is supported by much
research (Bang & Deyle 2000; Desmeules et al 2003; Green
et al 2003; Michener et al 2004; Dickens et al 2005; Jonsson
et al 2006; Trampas & Kitsios 2006; Senbursa et al 2007;
Lombardi et al 2008; Baydar et al 2009; Chen et al 2009; Kuhn
2009; Roy et al 2009). Furthermore, outcomes following con-
servative treatment (incorporating therapeutic exercise)
appear to be similar to those after surgical intervention in
SAIS and rotator cuff lesions (Haahr & Andersen 2006;
Dorrestijn et al 2009). This key role of therapeutic exercise in
shoulder rehabilitation is emphasized by the fact that good
clinical outcomes have been associated with normalization of
scapular kinematics (Roy et al 2009) and recovery of strength
(Nho et al 2009).
Principles of Exercise
A clinical assessment should be completed prior to exercise
prescription and clinicians should remain cognisant of the
various facets of an exercise programme and suit the needs
to the individual patient: posture, flexibility and stretching,
stability, strengthening, proprioception and functional pro-
gression (Tippet & Voight 1995; Lephart & Fu 2000; Alter
2004; Donatelli 2004b, 2006; Kraemer & Ratamess 2004;
Weerapong et al 2004; Houglum 2005; Kendall et al 2005;
MacIntosh et al 2006). It is important for the clinician to gather
information including the subjective history, objective exami-
nation, special tests, functional ability, impairment, dysfunc-
tions, diagnosis and any other pertinent information. Two-way
communication with other team members (e.g. medical, sur-
gical, psychological, coach, strength and conditioning, etc.)
is essential in order to enhance the overall physical therapy
plan of care, and set appropriate and safe goals. Clinicians
should employ evidence-based practice and clinical reasoning
with respect to current research, and patient-orientated
goals as the basis for rational rehabilitation (Cicerone 2005).
Safety is of paramount importance and clinicians should
ensure that exercises are suitable and safe for individual
patients. Furthermore, since painful sensory input may alter
motor output during exercise, reduction of the pain where
possible with appropriate physical, pharmacological and / or
psychological strategies is an important part of the rehabilita-
tion process.
There are three phases of a therapeutic exercise pro­
gramme, which are worked through progressively based on
the requirements of the individual patient; these include: (1)
posture, joint range of motion and flexibility, (2) muscle
strength and endurance, and (3) functional aspects including
proprioception, coordination and agility (Houglum 2005).
For example, the exercise prescription and goals of a patient
with adhesive capsulitis will differ significantly from those
of a patient with humeral instability. Principles for guiding
rehabilitation include avoidance of aggravation, timing of
 Principles of exercise 375

Therapeutic exercise programme

Patient assessment Rehabilitation principles Phases of exercise programme (1–3)

(Houglum 2005) (Houglum 2005)
Patient characteristics
Clinical information Monitor and reassess
Avoid aggravation – adapt accordingly
Impairments /Dysfunctions /Diagnosis
Safety /Suitability /Goals Suitable exercise within clinical limits Safety
Treatment Monitor for aggravation
Communication with team members
Timing
1 Range of motion
Time within clinical limits
Anatomy/ Physiology Start early as appropriate Posture
Function Monitor and progress Flexibility
Range of motion
Biomechanics-pathomechanics
Compliance
Pathology
Education, demonstration
Healing pathway Set goals 2 Muscle strength
1. Inflammation Reduce fear avoidance Muscle strength and endurance
2. Proliferation Avoid over-exertion
3. Maturation
Individualization
3 Functional
Prescribe individual programme
Guiding principles Proprioception
Relate to specific needs and goals
Evidence-based practice Coordination
Suitability and safety Agility
Specific sequencing
Wolff’s law/Davis’s law Function
Specific Adaptation to Progress as indicated
Imposed Demands (SAID) Elements of exercise programme (1–3)
Concentric/Eccentric
Intensity Aggravation–red flags
Open and closed chain exercise
(adapted from Tippet & Voight 1995)
Address healing pathway
Technique (Tippet & Voight 1995) Consider tissues Change in /presence of
Carriage / Confidence / Control Need to challenge patient 1. Swelling
2. Pain
Tools Total patient 3. Range
Elastic bands, weights, machines, Injured and uninjured body parts 4. Loss of strength
pulleys, mirror and biofeedback Psychology 5. Function
therapy, EMG, aquatherapy etc. General fitness and cardiovascular 6. Specific clinical tests

Figure 33.1  Principles of therapeutic exercise.

exercise, compliance, individualization, specific sequencing,
intensity and total patient approach (Houglum 2005); these
principles are presented in Figure 33.1.
Exercise programmes should be progressive and graded
according to the stage of healing and should not aggravate
pain, swelling or result in deterioration in other clinical
signs such as range of motion, strength and function (see
Fig. 33.1) (Tippet & Voight 1995). The ability to perform
exercises with appropriate skill should be monitored closely
(Tippet & Voight 1995). These authors referred to the three
‘C’s: (1) carriage – appropriate weight shift, weight accept-
ance and symmetry of movement, (2) confidence – verbal
and non-verbal communication, speed and deliberateness of
exercise performed, and (3) control – smooth unrestricted
automatic movements with skilled task performance (Tippet
& Voight 1995).
Bone and soft tissues adapt according to the stresses placed
upon them, which highlights the importance of appropriate
loading of tissue in a graded progressive manner to enhance
healing, and has been described by Wolff’s law and Davis’s
law respectively (Wolff 1986; Tippet & Voight 1995). These
principles also apply to the hypertrophy of uninjured tissues;
for example, it has been demonstrated that baseball athletes
have thicker biceps and supraspinatus tendons compared
with non-athletes (Wang et al 2005). On the other hand, over-
loading of bone and soft tissue can result in injury such as
bone stress fracture or tendon failure.
The principle of specific adaptations to imposed demands
(SAID) refers to the body’s ability to change according to
specific demands placed upon it and therefore has implica-
tions for rehabilitation design in that exercises should mimic
the expected functional stressors of the individual patient as
much as possible (Houglum 2005). Implementing variance of
activities and rest phases is important so as to allow adapta-
tion. An example of the relevance of these principles is when
considering the introduction of eccentric strength training
into the rehabilitation programme. Eccentric strength training
programmes appear to be effective in the management of
knee and ankle tendon pathology (Alfredson et al 1998; Young
et al 2005). There has been less research on eccentric pro-
grammes for rotator cuff tendon pathology; however, initial
results are encouraging (Jonsson et al 2006). Eccentric pro-
grammes are, however, associated with muscle damage
(Clarkson & Hubal 2002). Before placing such high stresses on
previously injured tissues, basic isometric and isotonic
strength programmes should be already in place. Further, the
introduction of such eccentric training programmes should be
progressed.
 376 PART 4  • 33 • Therapeutic exercises for the shoulder region
Shoulder muscle balance ratios have been reported, includ-
ing ratios between the external and internal rotators of 1.5 : 1
(66%) for both fast and slow isokinetic torque arm speed in
normal subjects (Ivey et al 1985). Ratios have also been pre-
sented for professional baseball pitchers (Ellenbecker &
Mattalino 1997). Clinicians should consider these ratios in
exercise programme design. A discussion of isokinetics is
beyond the scope of this chapter, but has been reviewed by
Ellenbecker and Davies (2000).
The following sections will discuss, posture, stretching and
strengthening (isometric and isotonic) and briefly mention
functional exercise. Specific parameters for timing and repeti-
tions of stretching and strengthening will be covered under
each appropriate section.
Posture
Postural assessment is an important part of the objective eval-
uation and ideal static postural alignments have been sug-
gested (Kendall et al 2005). However, it is important to assess
both static and dynamic postures to ascertain the patient’s
functional movement and ability to self-correct a static habitus.
An example of this is a boxer, who enhances a hyperkyphotic
and rounded shoulder posture to reduce his target size for
strategic advantage, but when dynamically tested may be able
to self-correct the seemingly poor posture.
It is important to assess for muscle length, joint mobility
and muscle control. Altered posture may be related to muscle
imbalances and altered joint position, which ultimately could
result in movement dysfunction and pain. Deviations in
normal upright positions may include a forward head posi-
tion, an exaggerated curve in the thoracic kyphosis, and
rounded shoulders. Deviations in scapular kinematics may
present in multiple planes, including changes in scapular
elevation, protraction, tilt and rotation, affecting the size of
the subacromial space (Solem-Bertoft et al 1993), as well as
both activation (Roy et al 2009) and mechanical advantage
(Kibler et al 2006) of muscular structures. It has been demon-
strated that the size of the subacromial space is reduced in the
presence of thoracic hyperkyphosis (Raine & Twomey 1997;
Gumina et al 2008) and shoulder protraction (Solem-Bertoft
et al 1993). It is, however, uncertain whether a strong correla-
tion exists between narrowing of the subacromial space and
shoulder symptoms (Graichen et al 2001; Roberts et al 2002;
Hinterwimmer et al 2003; Lewis et al 2005; Mayerhoefer et al
2009). In fact, although it has been assumed that there is a
definitive association between these postural deviations, a
study of 160 asymptomatic subjects found no such correlation
(Raine & Twomey 1997). Therefore, although there may be a
relationship between posture and subacromial space, this is
not yet fully understood.
Thoracic kyphosis and forward shoulder position influence
the length of the upper back and scapular muscles and place
the intervertebral joints in an end-range position (Griegel-
Morris et al 1992). The sustained strain on these soft tissues
may lead to upper back pain or shoulder pain. In the front of
the body the pectoral muscles may shorten (Borstad &
Ludewig 2006; Muraki et al 2009). Sustained muscle shorten-
ing may lead to the development or activation of myofascial
trigger points (Simons et al 1999). Referred pain from the
pectorals may be felt in the front of the shoulder and arm
(Simons et al 1999) and sometimes even in the upper back
region (Dejung et al 2003). (See Ch 59 for a review of these
mechanisms and muscle referral patterns.)
Sustained contractions impair normal blood flow in skel-
etal muscles. Optimal posture allows muscles the opportunity
to relax in between contractions, which permits and facilitates
recovery of circulation (Otten 1988; Sjogaard & Sogaard 1998;
Palmerud et al 2000). Combining postural exercises with
myofeedback / EMG is helpful when teaching patients how to
use their muscles in an economic and healthy manner (Peper
et al 2003; Voerman et al 2006). Though there is a wide range
of postures, clinicians should consider the optimal posture for
each patient and individualize exercise programmes, rather
than focusing on an idealized posture suitable for all. Assump-
tion of an appropriate upright trunk posture can change
muscle activation and modify range of motion and symptoms
(Bullock et al 2005). Scapular taping can be used as a tempo-
rary means of altering scapular muscle activation (Selkowitz
et al 2007). Furthermore, Lucas et al (2004) demonstrated that
latent trigger points can alter muscle activation patterns of the
shoulder as assessed by EMG and subsequently reported that
dry needling and stretch, when compared with placebo ultra-
sound, was found to improve the muscle activation patterns
significantly and similar to controls.
Treatment for postural dysfunctions may include manual
therapies, including: joint mobilization and manipulation,
massage and myofascial trigger point release, myofascial
release techniques, trigger point dry needling, biofeedback
and EMG, stretching, stability and strengthening and cogni-
tive and behavioural strategies.
Stretching
Flexibility and stretching is a broad topic with conflicting
opinions in the literature, and a full discussion of this topic is
beyond the scope of this chapter. Readers are referred else-
where for a comprehensive review of stretching (Alter 1996;
Weerapong et al 2004). A rehabilitation programme of the
shoulder may incorporate a muscle-stretching programme,
which is usually employed for muscle lengthening and associ-
ated clinical implications, pain inhibition and potential injury
prevention.
It has been reported that alterations in scapular movement
are related to changes in myofascial length (Borstad &
Ludewig 2005; Borstad 2006). The addition of appropriate
manual therapy techniques may increase the effectiveness of
therapeutic exercise (Winters et al 1997; Conroy & Hayes
1998; Bang & Deyle 2000; Desmeules et al 2003; Bergman et al
2004; Michener et al 2004; Senbursa et al 2007; Boyles et al
2009). These techniques may include soft tissue techniques,
passive stretching and joint mobilization, and may increase
range of motion in subjects with shoulder pain (Vermeulen
et al 2006; Johnson et al 2007). Therapeutic exercise alone,
however, may be as effective as adding passive joint mobiliza-
tions to therapeutic exercise (Trampas & Kitsios 2006; Chen
et al 2009). (Different joint mobilization techniques are
described in detail in Ch 31.)
A muscle-stretching programme should be based on assess-
ment of muscle length and end feel. Muscles and fascia may

Figure 33.2  Levator scapula stretch. Ipsilateral arm-elevated position is
proposed to assist in isolating the levator scapula from the upper trapezius.
present with neuromuscular, viscoelastic or connective tissue
alterations (Chaitow & Liebenson 2001). It is important to
evaluate muscle length, and its influence on the length–
tension relationship should not be overlooked (Janda 1993;
Sahrmann 2002; Ekstrom & Osborn 2004; Kendall et al 2005).
Though individual patients will present with varying degrees
of muscle length, the following patterns, as outlined by Janda
and others, are often seen in clinic practice (Chaitow &
Liebenson 2001):
• short muscles and often facilitated: pectoralis major and
minor, latissimus dorsi, levator scapula, upper trapezius
(at times)
• long muscles and often inhibited: serratus anterior,
lower and middle trapezius.
A stretch for the levator scapula and a clinician-assisted
stretch for the pectorals and latissimus dorsi muscles are pre-
sented in Figures 33.2 and 33.3 respectively. Other self-stretch
exercises for the pectorals and latissimus dorsi may include
the doorway stretch and one-sided unilateral self-stretch of
the pectoralis minor, which has been shown to be superior to
a supine manual stretch and a sitting manual stretch (Borstad
& Ludewig 2006).
Muscle-stretching techniques include static, ballistic,
dynamic and proprioceptive neuromuscular facilitation
(Weerapong et al 2004; Houglum 2005). Other techniques
have been described including post-isometric relaxation
(Lewit & Simons 1984; Lewit 1986, 1999), muscle energy tech-
nique (Greenman 1989; Chaitow & Crenshaw 2006), activated
isolated stretching (Mattes 1995) and spray and stretch (Travell
& Simons 1983; Simons et al 1999; Kostopoulos & Rizopoulos
2008). Stretching has been employed for the treatment of pain,
especially in relation to the treatment of myofascial trigger
points (Simons et al 1999).
Stretching 377
Figure 33.3  Pectoral and latissimus dorsi, clinician-assisted stretch. The
patient maintains a neutral lumbar spine and a towel can be used to reduce thoracic
kyphosis. The clinician applies a low-grade smooth stretch against soft tissue
barrier. For appropriate modesty, the patient’s opposite hand can be placed across
the chest and the clinician’s hand can be placed on top. Contract relax application
can also be added to augment stretch.
The recommended duration of static stretching varies, but
it is reasonable to recommend a 15–30-second hold with 3–5
repetitions (Taylor et al 1990; Houglum 2005) repeated daily
or several times / day. Good form should be maintained
during stretching technique, which should be smooth and
within the clinical limits of the presenting problem. Longer
hold times up to and beyond 5 minutes have been recom-
mended for fascial tissue release (Barnes 1999).
Patients with a history of subluxation, dislocation, hyper-
mobility of the shoulder or general hypermobility syndrome
need to be identified, as a stretching programme may be inap-
propriate and potentially detrimental in these individuals.
The patient history, muscle length tests, joint end feel, passive
joint tests and the Beigthon score (Alter 1996) may assist the
clinician in identifying hypermobility and instability. Up to
11.7% of people have some form of joint hypermobility, and
this has been reported to be up to three times more prevalent
in females than in males (Hakim & Grahame 2003; Seckin
et al 2005).
The majority of current research does not support the
hypothesis that stretching prevents injury (Shrier 1999;
Weerapong et al 2004). However, there is some evidence to
suggest that lower limb stretching can reduce the risk of
injury (Hartig & Henderson 1999; Amako et al 2003; Jamtvedt
et al 2009), or the rate of return from injury (Malliaropoulos
et al 2004). Interestingly, though, reviewed research on
stretching has demonstrated a negative effect on muscle
strength and functional performance (Weerapong et al 2004).
Further, the fact that most research has focused on the lower
extremities raises validity issues about the validity of extrapo-
lating the findings to the upper extremity. However, clinicians
should consider these issues when prescribing flexibility pro-
grammes, especially in relation to performance athletes and
players. More research is required to assist in a better under-
standing of the role of stretching in injury management and
prevention.
External rotation is fundamental for elevation and shoul-
der function and it is important to restore passive and active
external rotation (Donatelli 2004a). External rotation is
 378 PART 4  • 33 • Therapeutic exercises for the shoulder region
Figure 33.4  Subscapularis stretch, self-assisted stretch with cane. The supine
position offers stability of the scapula while external rotation of the glenohumeral
joint is assisted with self-control using the cane. A towel is placed under the elbow
to maintain alignment of the humerus.
primarily limited at 0° by the subscapularis, at 45° of abduc-
tion by the subscapularis, middle and inferior humeral liga-
ment and at 90° of abduction by the inferior humeral ligament
(Turkel et al 1981). Muscle length testing of the subscapularis
is carried out with the arm in neutral and testing into external
rotation (Donatelli 2004b). An auto-assisted stretch for the
subscapularis, using a cane, is presented in Figure 33.4. The
stretching position, for example at 0°, 45°, 90° abduction, etc.,
should be based on any restrictions of the subscapularis and
humeral capsule and ligaments identified from the physical
assessment. The contribution of the humeral joint capsule
(and other posterior soft tissue structures including the infra-
spinatus, teres minor and deltoid) to shoulder movement
should not be overlooked and has been proposed to be par-
ticularly important in certain shoulder disorders, including
SAIS (Donatelli 2004a). Reduced cross-body adduction has
been linked to tightness of the posterior capsule, and associ-
ated with abnormal humeral translation (Ludewig & Cook
2002). Cross-body adduction and the ‘sleeper stretch’ (internal
rotation of the shoulder in 90° of shoulder flexion) have been
recommended as stretches for posterior shoulder capsular
tightness (Cooper et al 2004; McClure et al 2007; Laudner
et al 2008). The ‘sleeper stretch’ is presented in Figure 33.5.
However, modification into less shoulder flexion may be nec-
essary if symptoms are aggravated in this position.
Isometric Exercise of the Shoulder
Isometric exercise is usually utilized in the early phase of
rehabilitation to minimize muscle atrophy when movement
of the shoulder is limited. Studies have demonstrated up to
a 41% decrease in isometric strength after immobilization
of the upper extremity for 5–6 weeks, with significant
decreases in muscle fibre area by 33% and 25% for fast- and
Figure 33.5  Sleeper stretch. The 90° position stabilizes the scapula and
downward pressure is applied with a self-stretch to the opposite hand into internal
rotation.
slow-twitch fibres respectively (MacDougall et al 1980).
During immobilization of the upper limb, strength training
with maximal isometric exercise 5 days / week of the free limb
may prevent atrophy of the immobilized limb (Farthing et al
2009). Further research has suggested that adding a 0.5 kg
weight to the ipsilateral hand during isometric and dynamic
shoulder exertions increases shoulder muscle activity by 4%
maximum voluntary excitation (Antony & Keir 2010). Static
exercises for the shoulder are presented in Figure 33.6. A belt
is employed to allow multidirectional static exercises;
however, other options include resistance against a wall. A
hand-held weight of 0.5 kg is used to assist in increasing
shoulder muscle activity (Antony & Keir 2010). Suggested
parameters for isometric exercises include pain-free 5- to
10-second holds with 10 repetitions, graded to maximal con-
traction and repeated several times per day with progression
as indicated (Houglum 2005).
Isotonic Exercises of the Shoulder
There is a plethora of exercises for the shoulder girdle, and
research employing EMG has aimed at identifying exercises
that target specific shoulder muscles; here we briefly review
a selection of exercises that target the rotator cuff, trapezius
and serratus anterior muscles. For a further expansion of
this, readers are recommended to review other publications
(Ekstrom & Osborn 2004; Houglum 2005; Reinold et al 2009).
When designing a strengthening programme, the clinician
should target muscles identified as weak during the evalua-
tion and, on the basis of this, prescribe suitable exercises.
The clinician should prescribe the specific exercise, resist-
ance (or none), repetitions, sets and frequency of the pro-
gramme. This programme should be monitored, adjusted
and advanced progressively. A programme can be initiated
with or without weight, as appropriate. Recommendations
have been made in relation to exercise repetitions (reps) and
include 1–6 reps for strength, 6–12 for hypertrophy and
12–15 for endurance (Kraemer & Ratamess 2004). The weight
used is appropriate to cause fatigue towards the end of
the stated number of repetitions. It has been found that two

to six sets per exercise produced significant increases in
muscular strength in both trained and untrained individuals
(Kraemer & Ratamess 2004).
Other recommendations include 6–15 repetitions of two
sets where the patient can control the weight, progressing to
20–25 repetitions of three sets (Houglum 2005). When this is
reached, the weight then is progressed accordingly and the
process started again with 6–15 repetitions of two sets, etc.
(Houglum 2005). There are various exercise progressions that
can be considered including that of Delorme and Watkins
(1948), Oxford technique (Zinovieff 1951) and daily adjusted
progressive resistive exercise (Knight 1985; Houglum 2005).
The clinician should consider the principles of exercise as
outlined in Figure 33.1 when prescribing strength pro-
grammes. The rotator cuff muscles are important stabilizers
of the humeral joint and assist in stabilizing the humerus in
the glenoid by compression and preventing shear and upward
movement of the humeral head during arm movements (Oatis
2004). Other muscles assist in stabilizing the scapulothoracic
complex and in dynamic stability (Oatis 2004) and these
muscle-specific exercises are covered below. For muscles such
as the deltoid, levator scapulae and rhomboids, and indica-
tions for strengthening, readers are recommended to review
the article by Reinold et al (2009).
Supraspinatus muscle
The supraspinatus is the most superior of the rotator cuff
muscles and lies deep to the subacromial bursa and the cora-
coacromial ligament within the subacromial space (Oatis
2004). The reported actions of this muscle include abduction,
external rotation and stabilization of the shoulder (Oatis
2004). Activity of the supraspinatus increases with increased
Isotonic exercises of the shoulder 379
Figure 33.6  Isometric exercises for
the shoulder. The use of a belt allows
the patient to perform isometric exercise
in multiple directions. This can be also
done against a wall. Internal and
external rotation is performed with
self-assisted resistance. The use of a
hand-held weight of 0.5 kg has been
shown to assist in increasing shoulder
muscle EMG by 4%. The arrows indicate
direction of force, but as an isometric
exercise there is no movement.
loading during abduction and scaption movements, peaking
at 30–60° of elevation (Reinold et al 2009). Reinold et al (2007)
demonstrated that EMG activity was similar across three exer-
cises: full can, empty can and prone full can. The full-can
exercise results in significantly less activity of the middle and
posterior deltoid, which may reduce harmful shear force on
the humeral joint from deltoid activity (Reinold et al 2007,
2009). In addition, it reduces the potential for subacromial
impingement because of the external rotation component
(Ekstrom & Osborn 2004). Moreover, this exercise has been
recommended by previous research (Kelly et al 1996). The
full-can exercise in the plane of the scapula with external rota-
tion of the shoulder is presented in Figure 33.7.
Infraspinatus and teres minor muscles
The actions of the infraspinatus and teres minor are primarily
external rotation and functionally assisting the stability of the
humeral joint during elevation movements (Reinold et al
2009). Stabilization of the shoulder by these muscles is also
achieved by opposing superior and anterior humeral head
translation (Reinold et al 2009). The infraspinatus has poten-
tially a role in abduction and horizontal abduction, with the
teres minor involved in adduction, the difference apparently
being due to different moment arms (Oatis 2004). EMG analy-
sis demonstrated the best isolation of the infraspinatus in 0°
abduction with 45° of medial rotation from neutral (Kelly et al
1996), and Reinold et al (2009) suggested incorporating this
position as an exercise to any rehabilitation programme when
focusing on increasing external rotation strength. Addition of
a roll support between the arm and the trunk (Fig. 33.8) has
been shown to increase EMG activity in the infraspinatus and
teres minor muscles by up to 25% (Reinold et al 2004, 2009).
 380 PART 4  • 33 • Therapeutic exercises for the shoulder region
Figure 33.7  Supraspinatus full-can strengthening. This is carried out in the
plane of the scapula, slowly and controlled with the thumb up to ensure a degree of
external rotation.
Figure 33.8  Infraspinatus and teres minor muscles strengthening. In side-lying,
the arm is brought from internal into external rotation. A towel positioned between
the arm and trunk has been shown to increase EMG of the muscles by 25%.
A second exercise worth considering is standing external rota-
tion in the scapular plane (45° of abduction) (Fig. 33.9) as this
has demonstrated good EMG activation of the infraspinatus
and teres minor (Reinold et al 2004), and isokinetic external
rotational strength values in the plane of the scapula have
been reported to be significantly higher than in the frontal
plane (Greenfield et al 1990).
Other exercises for external rotation have been recom-
mended that place the shoulder in a more compromised posi-
tion (e.g. external rotation in 90° abduction) and clinicians
should carefully consider the appropriateness of these exer-
cises in the presence of capsulolabral dysfunction and pathol-
ogy (Reinold et al 2009).
Figure 33.9  External rotation in the plane of the scapula. The shoulder is
rotated from internal to external rotation.
Figure 33.10  Subscapularis strengthening (Gerber’s lift-off test). The hand is
raised upwards from the trunk.
Subscapularis muscle
The subscapularis is the largest of the rotator cuff muscles and
acts to rotate internally, flex, extend, abduct, adduct, adduct
horizontally and stabilize the shoulder, with broad agreement
that internal rotation and stabilization are the primary roles
(Oatis 2004). Subscapularis weakness leads to significant
decrease in internal rotation strength and may contribute to
anterior instability of the shoulder (Oatis 2004). The lift-off
test as described by Gerber and Krushell (1991) has been
demonstrated to isolate the subscapularis (Greis et al 1996;
Kelly et al 1996). The lift-off exercise for the subscapularis
muscle is presented in Figure 33.10.
Trapezius muscle
The trapezius is an expansive muscle that has three distinct
muscle sections: upper, middle and lower, with each having

Figure 33.11  Trapezius strengthening. This targets the upper, middle and lower
sections of the trapezius muscle. The thumb is maintained in an upright position.
a distinct function and combining to assist in the overall func-
tion of the trapezius (Oatis 2004). The actions of the three
sections have been reported as follows (Oatis 2004): upper
trapezius – elevation of the scapula, adduction and upward
rotation of the scapula; middle trapezius – adduction of the
scapula; and lower trapezius – depression, adduction and
upward rotation of the scapula. In particular, the upper and
lower trapezius form an anatomical force couple that assists
in stabilizing the scapula, and maintaining a balance between
these muscle segments is important for optimal function
(Oatis 2004). Furthermore, the lower fibres have been reported
to play an important role in posterior tilt and upward rotation
of the scapula during shoulder elevation (Ludewig et al 1996).
Therefore, the lower trapezius and serratus anterior comprise
an important target for rehabilitation and prevention of shoul-
der dysfunction and impingement syndromes (Ludewig &
Cook 2000). With regard to exercises for the upper trapezius,
the shoulder shrug has been reported to produce the greatest
EMG activity (Ekstrom et al 2003). However, it has been
further reported that the shrug exercise also highly activates
the levator scapula and so if this needs to be avoided, owing
to the levator scapulae action of scapular downward rotation,
the military press may be more appropriate (Ekstrom &
Osborn 2004).
For the middle trapezius, abduction and external rotation
of the shoulder at 90° in prone (Fig. 33.11) has been shown to
induce good EMG activity and is considered a suitable exer-
cise (Moseley et al 1992; Ekstrom & Osborn 2004; Reinold et al
2009). This exercise has also been recommended for strength-
ening the trapezius as a whole, owing to high EMG activity
in the upper, middle and lower muscle segments (Ekstrom
et al 2003; Ekstrom & Osborn 2004).
The lower trapezius has been shown to be best activated
with the arm raise overhead exercise in the prone position,
performed at approximately 120° (Reinold et al 2009) to 135°
of abduction or with the arm positioned in line with the lower
fibres of trapezius (Fig. 33.12) (Ekstrom et al 2003; Ekstrom &
Osborn 2004).
Functional exercises 381
Figure 33.12  Trapezius strengthening. This targets mainly the lower fibres of
trapezius performed at approximately 120–135° of abduction or with the arm
positioned in line with the lower fibres of the trapezius.
Serratus anterior muscle
The serratus anterior muscle action has been reported as pro-
traction, abduction, upward rotation and elevation of the
scapula; the muscle functions in actions such as pushing a
revolving door and weakness may lead to winging of the
scapula and difficulty with overhead activities (Oatis 2004).
Shoulder abduction in the plane of the scapula above 120° (to
avoid painful arc) in the standing position has demonstrated
more EMG activity in the serratus anterior than does straight
scapular protraction (Fig. 33.13). The increased serratus ante-
rior activation should, however, be balanced against the
increased risk of impingement when exercises are performed
in elevation (Roberts et al 2002). Other recommended exer-
cises for the serratus anterior include the dynamic hug,
push-up with a plus and punch exercises (Decker et al 1999;
Reinold et al 2009).
Functional Exercises
The daily tasks and movements performed by the individual
should be considered when prescribing therapeutic exercise,
so that the exercises take into account the specific functional
demands of that person. Functional progression may include
movement from isolated plane to multiplane strengthening
(Fig. 33.14) and eventually plyometric exercise (Houglum
2005). Upper limb tasks are commonly open kinetic chain
movements. In athlete subjects with recurrent anterior shoul-
der dislocation, rehabilitation near / in the zone of instability
is indicated in late-stage rehabilitation and therefore tasks that
load the rotator cuff in semi-compromised positions may help
replicate the stability action required on return to sport.
Closed chain and stability exercises (Figs 33.15 and 33.16) for
the shoulder girdle are important to assist in motor control
and re-education (Houglum 2005) and are discussed in
Chapter 32. The shoulder girdle relationship to the kinetic
 382 PART 4  • 33 • Therapeutic exercises for the shoulder region

Figure 33.13  Serratus anterior strengthening. Shoulder abduction is performed in the plane of the scapula above 120° (to avoid painful arc) in the standing position.

Figure 33.14  Proprioceptive neuromuscular facilitation with elastic band.

Elastic bands can assist with creating open chain coordinated movements that
mimic functional patterns.
Figure 33.15  Shoulder dip. This is a closed chain kinetic loading and
proprioceptive exercise.

Figure 33.16  Prone knee, single-arm raise. The abdominals are primed prior to
the lift. This offers a closed chain exercise for weight-bearing shoulder and a
dynamic open chain exercise for the opposite arm. This exercise can be advanced
to alternative arm and leg lift for stability.
chain should be considered in the overall management of the
patient and exercise programmes may incorporate standing
balance and eye–hand coordination tasks, etc. (Donatelli
2006). A common barrier to shoulder rehabilitation is diffi-
culty in replicating the therapeutic exercise correctly at home,
possibly owing to reduced positional sense (Naughton et al
2005). Tasks that challenge the proprioceptive acuity and
load-bearing ability of the shoulder region may help to restore
positional sense awareness (see Figs 33.14–33.16). Clinicians
can also incorporate the use of exercise equipment to assist in
functional progression, including elastic bands, pulleys,
Theraballs, wobble boards, proprioceptive exercise devices
and feedback devices such as mirrors, etc.
Conclusion
Therapeutic exercises can play an important role in the man-
agement of shoulder pain. This chapter has outlined some
basic principles on the type of exercise that may be indicated
in the clinical setting, especially in relation to strength of the
rotator cuff and stabilizers of the scapula. Clinicians should
remain cognisant of the need for a comprehensive assessment
and ensure safe and suitable exercise prescription and pro-
gression. The nature, intensity and volume of exercise pre-
scribed must be matched to the clinical presentation.
Individual therapists may use the principles outlined in this
chapter as a guide when prescribing a therapeutic exercise
programme that is suitable for the needs of each individual
patient or athlete. Further research is required and should
focus on identifying exercises to suit the specific patient
presentation.
Acknowledgements
Thank you to the photographic volunteers: Derek Malone,
Irish Paralympic athlete and S.M.
Conclusion 383
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